29 June 2009

I make no secret for my admiration of Ezra Klein. He's an example of the sort of journalist we need more of -- he's identified his niche, is dogged in figuring out the intricacies of his subjects, and brings a fresh way of looking at things that I've often found valuable. But he's never worked in the health care industry, and book learning has its limits, as he demonstrated today:

Some of the folks I've talked with seem to think that because Congress sets [Medicare] prices, providers have to accept them. The long arm of the government reaches in and breaks the window and unlocks the door and pushes the elderly into the waiting room. But that's not true at all.

At the beginning of each year, providers decided whether they will do business with Medicare. In other words, they choose whether or not to accept public insurance like Medicare or Medicaid. Almost all of them choose to do so, because providing health services to Medicare patients is actually a very profitable business (Medicaid patients, less so).

I'm not really sure where to start with this, because it's breathtakingly wrong on several levels.

Let's start with the idea that Medicare patients are "profitable." First of all, profitable means different things to different specialties. If you're an orthopedic surgeon specializing in hip replacements, almost all of which are done to old people under medicare, then yes, the reimbursement for that procedure is adequate to pay the bills and provide a good living. Fair enough. If you are a primary care doctor, however, the reimbursement for that is a lot lower, low enough that alone it may not cover costs at all. Remember that primary care is a business and that docs have to pay rent, insurance, office staff and benefits, equipment, etc before they can pay their own salaries. The Medicare Professional Fee schedule has not had a meaningful update in well over a decade and in fact pays less well now than it did in 1995. That's in gross dollars, not inflation-adjusted dollars. Meanwhile, the other costs have gone up, some well in excess of inflation -- healthcare costs for office employees being a prominent and ironic example.

The result there is that most docs take a loss or at best break even on Medicare patients. The proof of this is the difficulty that Medicare beneficiaries have in finding physicians. Yes, most docs do still participate in Medicare, but they have capped the number of spots in their clinics available to Medicare patients. A practice with more than a certain fraction of Medicare is just not financially viable.

So why don't more docs just opt out? Part of it, from my experience talking to family docs, is that they feel an obligation to their existing patients and don't want to cast them out. A bigger reason, I suspect, is that there is a big disincentive for docs to opt out. If I cancel my group's Aetna contract today, and decide it was a mistake in four months, I can re-enroll and be up and running in their network within days. Medicare requires a two-year waiting period for docs who opt out before you can re-enroll in the program. If it turned out to be a bad business decision, then there's no take-back. That's a risk many docs are not willing to take.

The other consideration in the "voluntary" nature of Medicare participation is that many specialties are hospital based and as such are required by their hospital partners to participate in Medicare as a condition of being allowed to practice in the hospital. Every ER contract I have ever reviewed stipulated obligatory Medicare participation. Ditto for radiologists, anesthesiologists, pathologists, as well as many surgical specialties. So if you're an ER doc who does not participate in Medicare, I wish you well in finding a job, but you cannot work at any of my facilities! Whether an arrangement in which external agents compel participation in a voluntary program could be considered "voluntary" is an exercise left for the philosophers. As a practical matter, for any hospital-based doctor it is mandatory if you wish to be employed.

Turning to the practical extension, whether health insurance reform should include a government-run option:

If [the public plan] underpaid providers, providers would stop accepting it. And if they stopped accepting it, then people would switch to a private insurer because they'd want to be able to keep their doctor and they'd be willing to pay the difference to do so. Just as private insurers could lose members if their rates weren't low enough, the public plan could lose members if its rates were too low.

Depends. That's the "weak" version of the public plan, and I hope it's implemented. Proponents of a "strong" public plan would like to see its reimbursement linked to Medicare's and would like to see participation mandatory for docs who are on Medicare. Given that the public plan is itself at risk of elimination, I think the strong public plan is becoming vanishingly unlikely, so it's not the #1 fear I have these days.

I make no secret for my admiration of Ezra Klein. He's an example of the sort of journalist we need more of -- he's identified his niche, is dogged in figuring out the intricacies of his subjects, and brings a fresh way of looking at things that I've often found valuable. But he's never worked in the health care industry, and book learning has its limits, as he demonstrated today:

Some of the folks I've talked with seem to think that because Congress sets [Medicare] prices, providers have to accept them. The long arm of the government reaches in and breaks the window and unlocks the door and pushes the elderly into the waiting room. But that's not true at all.

At the beginning of each year, providers decided whether they will do business with Medicare. In other words, they choose whether or not to accept public insurance like Medicare or Medicaid. Almost all of them choose to do so, because providing health services to Medicare patients is actually a very profitable business (Medicaid patients, less so).

I'm not really sure where to start with this, because it's breathtakingly wrong on several levels.

Let's start with the idea that Medicare patients are "profitable." First of all, profitable means different things to different specialties. If you're an orthopedic surgeon specializing in hip replacements, almost all of which are done to old people under medicare, then yes, the reimbursement for that procedure is adequate to pay the bills and provide a good living. Fair enough. If you are a primary care doctor, however, the reimbursement for that is a lot lower, low enough that alone it may not cover costs at all. Remember that primary care is a business and that docs have to pay rent, insurance, office staff and benefits, equipment, etc before they can pay their own salaries. The Medicare Professional Fee schedule has not had a meaningful update in well over a decade and in fact pays less well now than it did in 1995. That's in gross dollars, not inflation-adjusted dollars. Meanwhile, the other costs have gone up, some well in excess of inflation -- healthcare costs for office employees being a prominent and ironic example.

The result there is that most docs take a loss or at best break even on Medicare patients. The proof of this is the difficulty that Medicare beneficiaries have in finding physicians. Yes, most docs do still participate in Medicare, but they have capped the number of spots in their clinics available to Medicare patients. A practice with more than a certain fraction of Medicare is just not financially viable.

So why don't more docs just opt out? Part of it, from my experience talking to family docs, is that they feel an obligation to their existing patients and don't want to cast them out. A bigger reason, I suspect, is that there is a big disincentive for docs to opt out. If I cancel my group's Aetna contract today, and decide it was a mistake in four months, I can re-enroll and be up and running in their network within days. Medicare requires a two-year waiting period for docs who opt out before you can re-enroll in the program. If it turned out to be a bad business decision, then there's no take-back. That's a risk many docs are not willing to take.

The other consideration in the "voluntary" nature of Medicare participation is that many specialties are hospital based and as such are required by their hospital partners to participate in Medicare as a condition of being allowed to practice in the hospital. Every ER contract I have ever reviewed stipulated obligatory Medicare participation. Ditto for radiologists, anesthesiologists, pathologists, as well as many surgical specialties. So if you're an ER doc who does not participate in Medicare, I wish you well in finding a job, but you cannot work at any of my facilities! Whether an arrangement in which external agents compel participation in a voluntary program could be considered "voluntary" is an exercise left for the philosophers. As a practical matter, for any hospital-based doctor it is mandatory if you wish to be employed.

Turning to the practical extension, whether health insurance reform should include a government-run option:

If [the public plan] underpaid providers, providers would stop accepting it. And if they stopped accepting it, then people would switch to a private insurer because they'd want to be able to keep their doctor and they'd be willing to pay the difference to do so. Just as private insurers could lose members if their rates weren't low enough, the public plan could lose members if its rates were too low.

Depends. That's the "weak" version of the public plan, and I hope it's implemented. Proponents of a "strong" public plan would like to see its reimbursement linked to Medicare's and would like to see participation mandatory for docs who are on Medicare. Given that the public plan is itself at risk of elimination, I think the strong public plan is becoming vanishingly unlikely, so it's not the #1 fear I have these days.

Ohio is the latest state to introduce new legislation that would dramatically increase the legal standard to win a civil suit against a doctor working at an emergency department [...] physicians would have qualified civil immunity while working in emergency rooms and be subject only to lawsuits if they showed “willful or wanton misconduct” — a high standard for liability usually reserved to determine punitive damages.

This is an interesting example of a legislative trend that seems to be gaining steam. EMTALA is the pretext for this bill, and the "hook" that allowed Ohio ACEP to sell it to friendly legislature. But it makes no sense at all. There's no reason why the specialty of Emergency Medicine should be granted such great protection from malpractice liability compared to every other medical specialty. Yes, we bear significant costs under EMTALA, which was an ill-conceived unfunded mandate which unfairly compels healthcare providers to work for free. And yes, I believe that the medial liability system is unfair and too expensive. I also agree that Emergency Medicine is an essential public health service, the proverbial safety net, and that access to emergency care needs to be protected and improved.

But with respect, WTF does EMTALA have to do with med mal reform?

Nothing. It's a great example of opportunism on the part of the EM lobby, and of the maxim that "hard cases make bad law." If med mal is broken, it should be reformed. If EMTALA is unjust, it should be funded or revised or made unnecessary through universal health insurance. But to "make up" for one bad policy by creating a carve-out for one specialty in another bad policy is just, well, it's bad policy.

This law, I might add, is extremely broad. I might even say excessive. Based on my quick read of the text, it implies that any doc who provides any EMTALA-compliant service is shielded from liability. Now I might have sympathy for a narrow law that basically shields docs who provide uncompensated care. That would have a certain degree of quid-pro-quo fairness to it: you have to see this patient for free, so the state will exempt you from liability in this case. Almost seems fair from the doc's point of view. But this law would seems to apply to any patient whose presentation invoked EMTALA, which is to say any patient who "comes to the ER" -- even funded patients. If someone comes in, I see them and they pay me for that service, why then should I be exempted from any consequences of my care? It makes no sense. Basically, what this would mean is that in Ohio, ER docs would be all-but-immunized from liability.

Wow. That's a big gift to ER docs. But believe it or not, it's still inadequate to "make whole" the profession from the costs of EMTALA. If we were to assume (optimistically) that the costs of med mal insurance and out of pocket expenses were to go to zero for ER docs as a result of this bill, that would save the typical ER practice 3-8% off their bottom line. It's not uncommon, however, for ER groups to see 15-20% of their patients without insurance, and 25-40% of their patients as functionally unreimbursed, given the vagaries of Medicaid. So the value of this carve-out still falls far short of the cost of EMTALA.

And never mind, of course, that if you are a patient harmed by an ER doc (it does happen from time to time) you are out of luck in seeking justice.

Happy wonders whether this immunity would extend into the inpatient setting. I suspect that would be a matter for a judge to interpret, but the case law of EMTALA suggests that necessary "stabilization" treatment is compelled under the act and so a decent argument could be made that "stabilization" treatment is covered and that particular cases would have to flesh out that boundary.

None of this is to argue that the current med mal system is just great and not in need of reform. I can see why this approach has its appeal. It's a lot easier than the real work of tackling med mal reform head on. It addresses not one but two chronic grievances of ER docs. It's more likely to bear fruit -- in most jurisdictions, ER docs have a certain credibility among lawmakers as the "good guys." But a patch that is inadequate, logically disconnected from the problem, unfair to patients, and excessively broad is not the right solution.

22 June 2009

It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.

But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.

Not surprising in the least. I'm actually astonished that there's anybody with the chutzpah to defend extended work hours for residents. I did my residency largely in the pre-hour-restriction era -- there were hour restrictions on months in the ER, but effectively none for the off-service rotations -- and it was a terrible way to deliver care. I did my time of q3 call in the units and q2 call on surgical services. This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital. That gives a new meaning to being a "resident physician!" (Actually, that's the original meaning, if you must get picky about it.)

The care provided was just scary. I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte. And I did get through it better than most. But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes. I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight. Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it! Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up. But I apparently did it by reflex without actually achieving a state of full wakefulness. This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight. Great training, but not so great for the patients who were the victims of the mistakes.

It seems to me that the defenders of the status quo have donned their rose-colored glasses. They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment. And there's the faux toughness: "I got through it, they can, too if they're not too weak." And the old guard romanticize the qualities of the "true physician" in their dedication to their patients above all else: "These younger doctors just don't care enough."

What a load of crap.

Look, it's with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drviers, airline pilots, etc), and it's stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors. When it's inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.

I also question the motivations of some of those who defend the status quo. It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government's dime are the ones to insist that the situation is just fine, or that "the evidence of benefit is lacking." How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on "efficacy, safety and cost" before making any changes? That's balls! It's also fairly blatant obstructionism and should not be given any credence.

Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.

I would also take issue with Dr Bob's comment that this "training system that has served our profession well for many years." I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I'm sorry, "rigorous") environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.

It is true that change might be painful. Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians. This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers. Maybe it doesn't make sense to have a surgical resident "running the book" -- many surgical residents never see the inside of the OR till their second and third years. The universities might have to hire PAs or NPs for the "scut work" instead of using MDs in training as glorified secretaries (what a waste of time and money).

I'm glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations. The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules. That effected the desired change, I can tell you! Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.

We said goodbye to one of our two remaining cats today. Zanzibar Buck Buck McFate (of course there's a Dr Seuss wiki) was eleven, and she went peacefully at the vet's office. She was a great cat, full of personality and incredibly social, especially for a cat. She was great with the kids in particular.

As this is a medical blog, I'll share some interesting details. She had developed some dramatic weight loss and wasting over a couple of months, and we got an ultrasound which confirmed a gastric lymphoma:

She was a pretty sick kitty at the end, but this morning she really rallied, taking a patrol around the house and even jumping on my lap at the desk, which she hasn't done for weeks. It made it a little harder to say good-bye, but it was necessary. The boys and all of us were there with her at the vet's when she closed her eyes for the last time. I'm going to miss that cat.

21 June 2009

So very many polls being run on the "public option" I almost feel like we're back in mid-October again. Still, the results are pretty encouraging for those of us who are in favor of a real public plan being included in the reforms.

For example, the NYT/CBS Poll shows strong support for the public plan being included as an option:

With people even being willing to pay higher taxes for it! That's a first.

The NBC/WSJ poll gives fairly similar results, with 76% of respondents agreeing that a public plan option is "Quite important" or "Extremely important," which I would assumes indicates support. In this poll, however, people are less willing to pay higher taxes to accomplish this. The Kaiser Family Foundation poll shows about 67% support for a public option.

When I'm looking at polls, I tend to look to none other than our friend Nate Silver at 538.com for analysis. He's got a great rundown of all the polls, other than the NYT one which was released after he went to press. The summary is pretty encouraging:

Nate also breaks down each of the polls in terms of their reliability and potential bias.

The consensus seems to be that a public plan -- at least the option -- is pretty popular. I think this is fed not so much by an active desire of people to be insured by the federal government, but by general antipathy towards private insurance companies. I also suspect that although people who currently have insurance are generally happy with their coverage, the prospect of a guaranteed fall-back option is attractive to those who have worried about losing their insurance.

Hopefully the Democrats in DC who are wavering about the inclusion of a public plan (I'm looking at you, Max Baucus) will take some heart from this level of support, find some resolve, and get the job done.

WHOSIS, the WHO Statistical Information System, is an interactive database bringing together core health statistics for the 193 WHO Member States. It comprises more than 100 indicators, which can be accessed by way of a quick search, by major categories, or through user-defined tables. The data can be further filtered, tabulated, charted and downloaded. The data are also published annually in the World Health Statistics Report released in May.

Lots of cool stuff there. It took me about thirty seconds to pull the data necessary to make this cool graph:

Actually it took me more time to figure out how to make Google Docs make the graph!

I'm going to have to spend some time spelunking that data base. WHO rocks.

One of the great things about the blogosphere is that it has an inherently self-correcting mechanism -- when you put an opinion out there, especially if it is provocative and/or poorly-though-out, it's sure to draw some fire. You have the choice of defending your opinions, revising your opinions or ignoring all criticism and losing credibility. Given the controversial recommendation for reform I made, it's not particularly surprising that my op-ed contribution to the New York Times drew a lot of fire.

By the way, I'd like to thank the Times for giving me this opportunity to contribute; it was very humbling to be published on the same page alongside such accomplished and respected members of the health affairs community. Thanks also to Kevin for recommending me; now I'm officially a member of the damned liberal media! It was a fun exercise and very different from what I usually do. The topic was assigned in advance, rather than just writing about whatever the hell I want, and there was a strict limit on length -- 400 words. I went through multiple drafts and worked with their editor to bring it down to size and clarify some key thoughts for a general audience. Working with an editor is really a rewarding experience, by the way. Maybe I'll hire one for the blog.

There were over 300 comments on the op-ed (most not addressed to my bit): a lot of fodder for thought. I'd like to respond to some of them here.

Just to clarify, the restrictions of the op-ed format did require substantial simplification of my central recommendation. "The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians." This reform is broadly stated and highly simplified. This puts me in a situation like advocates of the infamous "public plan," in that it's easy to imagine it implemented in a worst-case way and attack it as wrongheaded, and difficult to defend it when the details are undefined. To expand just a bit: I'm not in favor of a blanket restriction on the income of specialists or even an across-the-board reduction in the procedural RVUs. I think the RVRBS is terribly flawed, however, and grossly overpays many (but not all) procedural services. One solution to this would be to start over and re-think the physician work component of the RVRBS on a line-by-line basis. With the current composition of the RUC, which is dominated by proceduralists, we would probably wind up with the same outcome. However, if the RUC were rebalanced, giving each specialty representation according to the number of physicians practicing that specialty, it seems likely that the reweighted comittee would view physician work differently. Anyway, it's tough to make a detailed argument for this to an audience who doesn't know anything about the RVRBS in 400 words, so simplification was necessary.

One point which the NYT elided over, by the way, was that I make no distinction when it comes to this proposal between surgeons and other specialists who are not surgeons per se but derive much of the income through procedures. Most prominently, this would include cardiology and gastroenterology. And while I use the shorthand "Specialists" for these folks, it's important to understand that many specialists do not perform many procedures at all (neurology, nephrology, etc). Changing compensation for procedures would not affect them.

Ian derided as "risible" the distinction between "cognitive" and "procedural" services. Certainly there is no implication that surgeons don't think! However, this is common terminology distinguishing CPT codes which are medical from those which are related to a particular procedure. Put more simply, the various E/M codes (Evaluation & Management) are the "cognitive" codes, and in fact many specialists rightly use those for their office consultations and other patient interactions which do not relate to a particular procedure. Also, there was a suggestion that to propose policy changes in such a simplified format was somehow irresponsible. I do not agree with this. If my op-ed were influential beyond my wildest expectations, and my proposals were to gain actual momentum, that would be a good thing. It's true that details would need to be added to ensure it was well-implemented; bad reform is worse than no reform. Starting the conversation, however, is a necessary step to positive change and in no way is "reckless."

I think it's also important to be aware of the assumption under which we are operating: this is a zero-sum game. In the current environment of increasing health care costs it is not realistic to expect that the amount of money available for physician compensation will increase. There is, at best, a fixed pool of money which must be divided up among doctors. It would be nice if we could have painless rebalancing of physician income by paying PCPs a lot more without impacting the income of other physician. But that's not where we are. If doctors' pay is going to change, for each winner there must be a loser. Similarly, I am assuming that the physician workforce will also remain more or less static -- that the number of doctors graduating every year from medical school (and IMGs) will not be drastically altered. Many people say that we have a shortage of physicians, or that we are developing a shortage. I don't know. But once again, in the zero-sum game, increasing the number of doctors practicing primary care medicine will necessarily reduce the number of doctors practicing specialty medicine.

There's no surprise that a proposition that the compensation of surgeons is too high evoked a highly defensive reaction from the surgeons who responded. Just for reference, I have no intent to demean, belittle, or vilify individual docs or the contributions made by particular specialties. All of us have a parochial feeling that "I work hard and I deserve the money I get." Most of us have a firm belief that we have earned our compensation (and perhaps a little more) through our hard labor and sacrifices. I'm no different. At the policy level, we need to get over that blinkered perspective and make decisions based on whether or not they are good policy. Within the confines of this discussion, the question is not "who deserves a certain level of pay," but "what incentives will this level of pay create, and are they the right incentives?" I don't know how to quantify hard work and correlate that with compensation (many nurses I know have a much harder job than I do.) There's no formula to relate the value created by a particular specialty with its reimbursement. It is, however, easy to see that the US is grossly over-supplied in specialists; the logical solution for this is to redefine the economic incentives in a way that will amend that imbalance.

Also, I have no "Robin Hood" social justice motive for this proposal. I don't care if an orthopod makes a ton more than I do. My liberal sensibilities didn't drive this recommendation. It's all about the incentives.

This does not mean that I think a surgeon and an internist should make the same amount of money. Specialty training is hard and there should still be an incentive for some people to go into it. The wild disparity in earning potential, however, is far beyond what is reasonable and should be reduced. The typical family doc, pediatrician, or internist makes $90-150,000; it's not uncommon for specialists to make $500,000-$1,000,000. The current system evolved with docs taking as much as they could get, which leaves unanswered the critical question of "how much is enough?" What's the critical threshold that would keep some docs in a given field, but encourage some who might have practiced specialty medicine to stay instead in primary care?

Some noted that Emergency Medicine is a well-compensated specialty, and implied that this somehow makes me a hypocrite. Hardly -- depending on the technical details of implementation, my proposal could reduce the compensation for my field and get me lynched at the next Scientific Assembly. I'm not volunteering for a pay cut and would not like it. Emergency Medicine is important and all that, but it's still not primary care. It strikes me as potentially good policy that my own specialty might be left out of any increase in "cognitive services" bonusing, and might possibly even lose income in the end.

A lot of the responses I've gotten are along the lines of "Don't you know that according to (my professional organization) there's already a shortage of (my specialty) and that if there aren't more of us we won't be able to provide enough of (my procedures)." True enough. There aren't enough ER docs, for that matter, at least according to ACEP. I'll assume charitably that these studies should be taken at face value. I agree that the specter of reducing access to any care, specialty or otherwise, is troubling. Going back to the zero-sum game, however, there is already a critical shortage of docs in primary care specialties and there is already greatly limited access to primary care services, which will worsen if universal health insurance passes. If it's an either-or, then there's no argument. Primary care must come first.

Maybe this is an argument for a markedly increased physician workforce, but I make that argument with hesitance. Many other countries have more physicians per capita, but they also have markedly lower compensation for the average physician. If we were to follow France's example and increase the number of physicians we have by 50%, that would dramatically increase the expense of physician services. Can the already over-budget health care sector afford that? Would policymakers respond by proportionately decreasing individual physician reimbursement?

If you've made it this far, thanks for reading. I'm sure that I'm entirely adn tragically wrong and you all can make that clear for me in the comments.

Steve Jobs, who has been on medical leave from Apple Inc. since January to treat an undisclosed medical condition, received a liver transplant in Tennessee about two months ago. The chief executive has been recovering well and is expected to return to work on schedule later this month, though he may work part-time initially.

If true, wow. Curiously, the WSJ doesn't cite any sources, not the "unnamed insider close to Jobs," not an Apple spokesbot, nothing. Which is really unusual for a story of this magnitude. But it's hard to imagine them running with it as a bold statement of fact if they didn't have rock-solid sources, and the timing is exactly as Apple would have chosen, Friday after market close, so I'm inclinced to believe it.

19 June 2009

In a week of discouarging developments on health care reform, the House of Representatives has stepped up and offered reform advocates reason for optimism.

Today, three House committees are unveiling a draft of reform legislation they've constructed together. That sentence alone is something to savor. Committee turf battles helped kill reform in 1993 and 1994. Now we have all three committees with jurisdiction acting as one, putting forward the same piece of legislation and vowing to go forward in continuing partnership.

18 June 2009

16 June 2009

There was a lot going on yesterday, what with the HELP markup and Obama's photo op at the AMA and all that, so I didn't get a chance to comment on Senator Jay Rockefeller's Consumer Choice Health Plan, a compromise or "weak" version of the public plan option, and I'd hate to let it pass unmarked:

Some details:

The Consumer Choice Health Plan [CCHP] will be financially self-sustaining… The Administrator will establish and fund a contingency reserve for CCHP in a manner similar to that of the contingency reserve established by OPM for the Federal Employees Health Benefits Plan. Funds to operate the plan shall be derived from premiums for individuals enrolled under the plan and from contributions by employers not providing private health benefit plans.[...] Premiums for the Consumer Choice Health Plan will be driven by enrollee benefit costs - not by administrative overhead or profit margins. To help enrollees afford the cost of coverage, the same health insurance subsidies would be provided to enrollees in CCHP as those offered to consumers enrolled in private health plans. [...] At a minimum, the Consumer Choice Health Plan would be required to follow the same insurance regulations as private plans operating in the exchange. CCHP would also be required to offer the same type of plans as private plans participating in the exchange.

Sounds like a good faith effort to devise a plan which can fairly compete with insurance companies.

Sen. Jay Rockefeller, D-W.Va., has emerged as a leading voice on the Finance panel for Democrats pushing for a robust, government-run, public-plan option. Rockefeller, who chairs the Senate Finance Subcommittee on Health Care, issued a proposal Wednesday for a public plan that would be an arm of the Department of Health and Human Services and pay doctors and hospitals at Medicare rates for its first two years.

Rockefeller's proposal takes aim at private insurers, which many Democrats believe are inefficiently run and overpay health-care providers. While Rockefeller's proposal would require the public plan to be "financially self-sustaining," the proposed plan would prove a tough competitor to the insurers because it could use existing Medicare provider networks.

"Private insurance companies want to have their cake and eat it too," Rockefeller said in a statement. "They want health-care reform to earn them maximum profits if they start covering millions of uninsured Americans."

Medicare rates aren’t all bad, but it’s unclear if doctors would be willing to accept lower fees from the new public option. In a competitive environment, a public plan that can’t attract providers will rot at the vine; in other words, to attract patients any plan would have to retain doctors its enrollees would want to see.

There's good and bad here, but mostly good. The positive element is that the Consumer's Choice Health Plan would be self-funded and self-sustaining, meaning that there would not be taxpayer subsidies for the health plan itself that would give the plan an "unfair advantage" over private insurers. While I'm unenthused that the initial reimbursement rates would be the Medicare rate, the silver lining there is that after the initial term, the CCHP would have to negotiate and compete for provider networks, which would likely result in more sustainable provider compensation. This is assuming that participation in the public plan is not compulsory for physicians, but the implication is pretty clear that it would not be. The plan (and indeed the exchange) would be open to all who want it -- not just people who are unable to find insurance elsewhere or whose employer does not offer insurance. Small businesses could participate, as could people who chose to opt out of their employer-sponsored plans, in contrast to some recent proposals which sought to shrink the pool of eligible participants in the public plan by only opening it to a limited group of people unable to get insurance otherwise.

We'll see if a proposal like this gets any traction. The Kennedy bill recently marked up had a great big blank in the slot for the public plan, but Rockefeller is on the Finance Committee, which is expected to release its own version of a reform bill soon. This could serve as a template for the public option in the Finance bill -- does Rockefeller have any influence with Baucus? I suppose we will see.

Last year I decided I just needed to let it go by. This year - pretty much the same. It is still too painful to plan to "celebrate" it in any way. We were in Hilton Head last year so it was a bit easier to let it go. This weekend I kept thinking about how we might have been having his party.

15 June 2009

After a spirited debate in the House of Delegates and a personal outreach from the President himself, the AMA has established its final position on the public insurance plan option that is expected to be included in the final reform package. Here is a brief video with a statement from AMA President Elect James Rohack, MD:

Obama obliquely made the point that physician compensation should change fundamentally: "[T]he reforms we propose are to reward best practices, focus on patient care, not the current piece-work reimbursement." Ezra Klein also stated it more directly: "if we paid doctors exactly the same amount overall, but made that money a yearly salary rather than a reward for volume of treatment, doctors would lose an important incentive to provide more health-care services than we actually need." This is in many ways a logical outgrowth of the expose on physicians' perverse incentives authored by Atul Gawande. Is the wonk consensus solidifying that the health care system would benefit if doctors were paid on salary?

I hope not, and I hope this doesn't happen on a large scale. Not because I'm a doctor looking out for doctors' interests, but because it's bad policy. As any MBA or business executive will tell you, when it comes to personnel management, you get the behavior you incentivize. For most physicians, the behavior that is promoted by the fee-for-service system is patient contacts, and this mode of compensation is important in maintaining physician productivity.

Consider the emergency department, for example. If I have a patient volume of 100 patients per day, this is for basic purposes a static demand that has to be met. As it is, if I staff this ER with a group of motivated and efficient docs seeing 2.5 patients per hour, I need to provide 40 physician hours of staffing daily, or about 15,000 hours annually, equivalent to about 10 FTEs (Full-Time Equivalents). Predictably, when you drop the direct correlation between how much work you do and how much you get paid, there is a decrement in productivity. This amount may vary but might easily be 10% or more; this is often defended by physicians who claim that by going slower they are providing better care, which is actually a fair point. The consequence, however, is that I will need to hire another physician to staff my department, and, writ large, there will need to be 10% more ED physicians nationwide to keep up with demand. If those docs don't materialize, then the ERs will back up and waiting times and boarding will increase.

The same phenomenon will apply to, say, a Family Practitioner seeing patients in the office. Currently, the patients are scheduled in 10 minute blocks with little down time, just to keep the practice profitable. If the doc goes on salary and can see fewer patients for the same income, why would he not? It would be great for patients, too. Wouldn't it be nice to sit down and talk with your doctor without those time constraints? But again, the demand for these services won't go away just because the docs are working slower, and the consequence is that more PCPs will be needed to serve the same population, or that access to primary care services will erode.

Now maybe if these salaries were skewed to favor cognitive services, there'd be lots of proceduralists and specialists who no longer wanted to work so hard and do all those unnecessary procedures in McCallam, Texas that cost the system so much money. They would all retrain in primary care, or the graduating med students would gravitate to primary care. Maybe if the workforce were opened up dramatically there would be enough docs to fill the need for primary care. I haven't seen these proposals floated in any serious venue, though, and my gut feeling is that is not going to happen

Even if it did, it wouldn't save money. If you add another doc in a salaried environment, you've added another salary to your payroll. If the nation's ERs and internal medicine clinics all added 10% more physicians, the compensation for physician services would rise by a similar proportion. Now maybe - just maybe - the equation would turn out to be a net positive, as cost savings were realized through higher quality and care coordination. But it will take quite an investment to find out.

I also wonder what the unintended consequences of getting rid of piece-work compensation will be. When I call a consultant who is going to be paid the same amount whether he sees my patient or not, will he be more likely to refuse to consult? As an ER docs, this is a non-trivial possibility.

None of this is to say that the fee-for-service system is perfect, or that it doesn't create perverse incentives. I'll admit that I don't know an easy counterbalance to the incentive doctor's have to "do more." But I have seen the difference between salaried and incentivized physicians and it's night and day, with the incentivized docs being more effective, more efficient, better motivated and happier. I'd hate to lose that.

And yet, as clear as it is that our system badly needs reform, reform is not inevitable. There’s a sense out there among some that, as bad as our current system may be, the devil we know is better than the devil we don’t. There is a fear of change – a worry that we may lose what works about our health care system while trying to fix what doesn’t.

The fear of change is all the more acute when the proposals for reform remain, even at this late date, very inchoate and vague. The process has been (reasonably) transparent, unlike in 1993, so at least the outlines and competing options have been apparent. But the fact that we still don't really know what's coming puts a lot of people, especially doctors who might favor reform, in the anxious and skeptical camp.

[Prior] efforts at comprehensive reform that covers everyone and brings down costs have largely failed. Part of the reason is because the different groups involved – physicians, insurance companies, businesses, workers, and others – simply couldn’t agree on the need for reform or what shape it would take. And another part of the reason has been the fierce opposition fueled by some interest groups and lobbyists – opposition that has used fear tactics to paint any effort to achieve reform as an attempt to socialize medicine.

Sadly, the physicians lobby -- the AMA -- has acted like any other lobby, and worse than many, in focusing its attention narrowly on the economic interests of its members. And I've seen fairly little from ACEP or the ACP or any of the other physicians' organizations speaking clearly about the reforms being considered. It's been a colossal failure of leadership on the part of the house of medicine.

We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care.

This hasn't gotten a lot of attention, I think because nobody knows what the heck we mean by it. But I worry a lot about bundling of payments. If there's one payment to multiple providers, possibly combining a facility and professional fee, who gets what fraction of it? That looks to be a case of three wolves and a lamb voting on what to have for lunch, no? And still, we're all in favor of paying for quality, but nobody knows how to define quality let alone compensate on the basis of quality.

And we need to rethink the cost of a medical education, and do more to reward medical students who choose a career as a primary care physicians and who choose to work in underserved areas instead of a more lucrative path. That’s why we are making a substantial investment in the National Health Service Corps that will make medical training more affordable for primary care doctors and nurse practitioners so they aren’t drowning in debt when they enter the workforce.

Small beer. Nice to know that he's aware of the economic disincentives to medical students to practice in primary care fields. Pity he doesn't have any more substantial ideas to address the problem.

Each time an uninsured American steps foot into an emergency room with no way to reimburse the hospital for care, the cost is handed over to every American family as a bill of about $1,000 that is reflected in higher taxes, higher premiums, and higher health care costs; a hidden tax that will be cut as we insure all Americans.

Amen.

I know there’s some concern about a public option. In particular, I understand that you are concerned that today’s Medicare rates will be applied broadly in a way that means our cost savings are coming off your backs. These are legitimate concerns, but ones, I believe, that can be overcome. As I stated earlier, the reforms we propose are to reward best practices, focus on patient care, not the current piece-work reimbursement. What we seek is more stability and a health care system on a sound financial footing. And these reforms need to take place regardless of what happens with a public option. With reform, we will ensure that you are being reimbursed in a thoughtful way tied to patient outcomes instead of relying on yearly negotiations about the Sustainable Growth Rate formula that’s based on politics and the state of the federal budget in any given year.

This is the sort of vagueness and ambiguity which hinders physician acceptance of the public plan. Yes, you have acknowledged (some of) our concerns. Great. So where does your administration stand on them? Can you tell us, clearly and distinctly, whether you think Medicare rates should be used in the public plan? Can you tell us whether participation in the public plan should be mandatory for physicians who participate in Medicare? Seriously, I'd like to know, and the fact that you're not willing to stake out a position on this, when you have on so many other policy points, implies that you think we're not going to like your answers. If you could assure us that the public plan you envision and you will lobby for is palatable, then it would be less likely that the AMA house of delegates would be voting on resolutions opposing the public plan.

[L]et me explain how we will cover the price tag. First, as part of the budget that was passed a few months ago, we’ve put aside $635 billion over ten years in what we are calling a Health Reserve Fund. Over half of that amount – more than $300 billion – will come from raising revenue by doing things like modestly limiting the tax deductions the wealthiest Americans can take to the same level it was at the end of the Reagan years. Some are concerned this will dramatically reduce charitable giving, but statistics show that’s not true, and the best thing for our charities is the stronger economy that we will build with health care reform.

Hmm? I thought that proposal died in the Senate Finance Committee.

Another way we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now because of the large number of uninsured patients they treat. But as the number of uninsured people goes down with our reforms, the amount we pay hospitals to treat uninsured people should go down, as well. Reducing these payments gradually as more and more people have coverage will save us over $106 billion, and we’ll make sure the difference goes to the hospitals that most need it.

I hear the hospitals are already going ape over this proposal. It's sad and it's predictable that as more and more interest groups see something they don't like in the reform package, the support for reform dwindles. I will be very interested to see if, in the end, any major groups like the AMA, AHA, AHIP, etc actually flip and come out in active opposition to the final package. Much will depend on how effective they are in neutering or averting the adverse elements of the plan.

Overall, I'm inclined to give this speech a solid "meh." He didn't speak directly to physician's concerns, and the physicians did not want to hear what he did have to say. But ultimately, this wasn't about the AMA. This was about the general public seeing Obama talk to the doctors and about creating the perception that the doctors are on board with reform. Based on the tepic and vague news conference the AMA leaders held, in which they did not stake out any major disagreements with the President, I would have to say that Obama succeeded in that objective.

LITTLE FALLS, N.J., June 12 -- Children should be placed in rear-facing car seats until they reach the age of 4, two British researchers said.

Oh God. Is it not enough that they now have to sit in boosters till they're basically old enough to obtain learner's permits? This would be hell to endure if it were actually legislated by some well-meaning state body. You just can't interact with your kids in the car when you are back-to-back. You can't see what they're doing without a Rube Goldberg set up of multiple mirrors, you can't hand them food or a toy without dislocating your arm or stopping the car, you can't turn around and hit them when they're getting sassy, and worst, they can't see the front-mounted video screens that make car rides of more than forty minutes bearable.

Someday there will be research that shows that children who never ride in cars at all have a 100% reduction in motor vehicle accident-related mortality compared to the peer cohort that did ride in cars, and it will be a Class B felony to put a child into a car. Or perhaps there will be legislation requiring that all children wear protective cocoons and stowed in reinforced cargo compartments. I don't know where this is going, but one thing is clear to me: Child Safety research must be stopped. Call your congressman today!

In closed-door talks, Mr. Obama has been making the case that reducing malpractice lawsuits — a goal of many doctors and Republicans — can help drive down health care costs, and should be considered as part of any health care overhaul, according to lawmakers of both parties, as well as A.M.A. officials.

Wow. Yay. Crisis over, let's move on to something else now.

Or maybe not.

Senator Max Baucus of Montana, the chairman of the Senate Finance Committee, is expected to outline his proposal for a health care overhaul this week, and aides said liability protection for doctors is not part of the plan.

So, I'm guessing that Obama's talk about supporting med mal reform runs about as deep as his comittment to gay rights. Which is to say that he'll put out some happy talk about it to appease a necessary constituency but won't twist any arms or spend any capital in Congress to actually make it happen.

Worse, the semi-concrete proposals I have seen don't look like they'll offer much protection. Jon Cohn at TNR links to a summary of a few options:

Disclosure-and-offer programs, in which health care providers disclose unanticipated outcomes of care to patients and make prompt offers of compensation. Patients do not waive their right to sueby accepting the offer, but reportedly, few go on to file lawsuits.

It's hard to see this as reform at all. Disclosures are nothing new any more, and it's always been good tactics to make an offer of compensation if there actually was substandard care. I doubt this will be embraced by the medical community, since when you do a disclosure you're basically giving a potential plaintiff a roadmap for their future lawsuit. You're basically relying on their sense of decency to avert a suit, and how that fact can be altered I cannot imagine. Another commonly cited option would be to:

create a federal "safe harbor," retaining the current process of adjudication but insulating physicians from liability if they adhered to evidence-based medical practices. For example, legislation introduced by Senator Ron Wyden (D-OR) in February would create a rebuttable presumption that care was not negligent if the physician followed accepted clinical practice guidelines.

Sound great, but good luck applying that standard. Consider Whitecoat's trial, in which the case seems to be hinging on the fact that the got the right diagnosis and performed the right treatment, but he may or may not have done so in a timely fashion. Presuming there even exist "guidelines" for a particular condition or presentation, there are so many technical variables in the execution of the care under these guidelines that I don't see how juries could be expected to put this into practice.

Consider a child with meningococcemia. It's a no-brainer that a child with this deadly infection needs to be given antibiotics as soon as possible to have a chance to survive, and there's probably a guideline out there that makes reference to "urgent" or "timely" administration of antibiotics. So, if a kid comes into my ER with a fever and petechiae and I don't get the Rocephin in for, say ninety minutes, was that timely enough? Or maybe the kid didn't have the rash on presentation, but at hour three of an extended ER work-up the rash is noted and then antibiotics are given? Or maybe I was too rushed, stupid or negligent to notice the rash and didn't give antibiotics till hour three. My point is that it's meaningless to say that "guidelines were followed" when it's impossible to write guidelines that cover every clinical circumstance. Worse, if implemented narrowly, the "safe harbor" would offer very very little protection, and if construed broadly, it would make it very difficult to actually distinguish negligent care from good care.

The reason I'm spending so much time on this point is that this proposal has had explicit endorsement from Obama himself, his Chief of Staff Rahm Emanuel and his physician brother, Ezekiel Emanuel, and key legislators like Senator Ron Wyden. It sounds great, but it too is just "Happy Talk."

The last option cited is the classic option of moving med mal cases to specialized health care courts of some variety. I've always thought this had great potential, but there doesn't seem to be any political support for it and it would certainly be fought tooth and nail by the trial lawyer's association.

So it's looking more and more like health care reform, if enacted at all, will probably not include any meaningful or effective national solution to the ongoing malpractice crisis. Plenty of "Happy Talk," but no action and no solutions. Not that I really expected any, coming from a Democratic President and a Democratic Congress, but hope does spring eternal.

14 June 2009

Jacob Hacker writes at TNR's health policy blog The Treatment about Senator Kent Conrad's compromise plan which replaces the public plan option with a national series of insurance co-ops. Ezra Klein had some of the details the other day, in which the "co-op" plan was ballyhooed as a brilliant solomonic compromise and also the necessary solution to the political problem that the "public plan" just doesn't have the votes to pass.

I just skimmed the interview and the details of the "compromise" because in my opinion Kent Conrad has only slightly more credibility as a loyal democrat and genuine reformer than does Ben Nelson. Which is to say very little indeed. I remember thinking it was an interesting notion, creative and maybe with some potential, but that it just wouldn't work, though I couldn't say why off the top of my head. Fortunately, The Treatment is there to provide a more rigorous explanation of my gut impression.

In short, the co-ops would not fulfill the critical element of the public plan: to provide a cheaper alternative to the commercial insurance market, which would in turn force private insurers to become more cost-competitive and thereby provide some containment to the exponential growth in health care costs. The problem with the proposal is that a national medicare-like public insurance option would be large enough to negotiate significant discounts from providers*, whereas a series of much smaller co-ops would lack the market position to do so and would in fact have to pay premium rates to contract with providers. As a result, the co-ops would probably not be cost-competitive with private insurers and would certainly not achieve any national cost savings. And as a "back-up," an insurer of last resort, the co-ops would not really be effective if they were more expensive than private insurers, which would be the case if they did not have the market position to negotiate discounts.

Hacker also writes that the public plan is necessary to act as driver of care quality, to set benchmarks and standards against which private insurers can be compared. I'm not sure this is actually a necessary component of the public plan -- Medicare is already doing much of the early work in this area and will always be the big dog in setting standards, like it or don't.

Hacker's summary line, I think, is quite accurate -- this is not a compromise, it's outright capitulation. And it's not like we're going to get a chance to come back and re-do this in a year or two. As Robert Reich wrote: This is it, folks. The concrete is being mixed and about to be poured. And after it's poured and hardens, universal health care will be with us for years to come in whatever form it now takes. So it's extra-important to get it right -- or as right as possible -- this time.

So, coming back to the political question of whether a reasonably strong public plan option has the votes to pass, or whether real, painful compromises are going to be necessary in order to get health insurance reform passed, Conrad's assertion that there aren't sixty votes is pretty questionable. He cites "three" democrats that are on the fence or opposed to the public option. Forgive me if I assume that he's one of them! The real question is whether these three democrats would vote to sustain a filibuster of the final bill. For sure, we can dilute it down right now and more or less ensure that we can get it by all sixty dems. (Assuming Senator Franken is ever seated.) But how far are they willing to play the brinksmanship game? Will, say, Ben Nelson or Mary Landrieu actually vote to filibuster a democratic health care bill? It's logical that they would try to exert all their leverage as swing votes while the bill is being crafted -- but when push comes to shove, I suspect that none of them would actually vote to oppose cloture. Any or all of them might cast a symbolic protest vote against final passage (which only takes 50), but I am dubious that they would actually join a republican filibuster. And even if they did, evidence is that the votes of Snowe, Collins or even Grassley (!) are gettable, given the right confluence of events.

What this means, I think, is that we are very close to being able to pass a pretty good bill. If there was a big reach necessary to overcome cloture, it would justify a big compromise to get it done. But being so close, a weak public plan (as opposed to a more robust option, which ironically I think to be worse policy) might be a sufficient compromise to bring the bill to its final up or down vote.

*Standard disclaimer: a well-designed public plan will do this through market-based, not compulsory means.

12 June 2009

This wasn't Gawande's point at all, and is something quite tangential to Klein's point:

The reason most Americans hate insurers is because they say "no" to things. "No" to insurance coverage, "no" to a test, "no" to a treatment. But whatever the problems with saying "no," what makes our health-care system costly is all the times when we say "yes." And insurers are virtually never the ones behind a "yes." They don't prescribe you treatments. They don't push you towards MRIs or angioplasties. Doctors are behind those questions, and if you want a cheaper health-care system, you're going to have to focus on their behavior.

Yes, doctors are a driver -- one of many -- in the exponentially increasing cost of health care. Utilization is uneven, not linked to quality or outcomes in many cases, and may often be driven by physicians' personal economic interests. All of this is not news, though certainly Atul Gawande wove it together masterfully in his recent New Yorker article. (I'm assuming you've all read it -- If not, then stop reading this drivel and go read it immediately.) Nobody disputes that doctors' behavior (and ideally their reimbursement formula) need to change if effective cost control will be brought to bear on the system.

But it's completely off-base to claim that insurers aren't one of the problems in the current system. There are two crises unfolding in American health care -- a fiscal crisis and an access crisis. I would argue that insurers are less significant as a driver of cost than they are as a barrier to access. Overall, insurers have, I think, only a marginal effect on cost growth, largely due to the friction they introduce to the system -- paperwork, hassles & redundancy and internal costs such as executive compensation, advertising and profits. It would be great if this could be reduced, but it wouldn't fix the escalation in costs, only defer the crisis for a few years until cost growth caught up to today's level. In the wonk parlance, it wouldn't "bend the cost curve," just step it down a bit.

But as for access to care, insurers are the biggest problem. It's not their "fault" per se in that they are simply rational actors in the system as it's currently designed. Denying care, rescinding policies, aggressive underwriting and cost-shifting are the logical responses of profit-making organizations to the market and its regulatory structure. Fixing this broken insurance system will not contain costs, but it will begin to address the human cost of the 47 million people whose only access to health care is to come to see me in the ER.

BALTIMORE - At one of the nation's top trauma hospitals, a nurse circles a patient's bed, humming and waving her arms as if shooing evil spirits. Another woman rubs a quartz bowl with a wand, making tunes that mix with the beeping monitors and hissing respirator keeping the man alive.

"It's self-hypnosis" that can help patients relax, he said. "If you tell yourself you have less pain, you actually do have less pain."

Alternative medicine has become mainstream. It is finding wider acceptance by doctors, insurers and hospitals like the shock trauma center at the University of Maryland Medical Center.

Man this is disgusting. I did a significant chunk of my residency at shock trauma, and it was a pretty rigorous place at the time. It's really disheartening to see quackery infesting that institution too. Orac has (as usual) much more, and is much more eloquent that I could be, so I'll leave it there and encourage you to just go read what he wrote.

11 June 2009

I was seeing a elderly gentleman for what appeared to be an acute stroke. He was, by the history provide by paramedics, a potential candidate for something called t-PA, which is a clotbuster medicine that if given within a certain time can completely reverse the effects of a stroke. But this time frame is not generous -- three hours -- and a lot has to happen in that time, so there is a real sense of urgency when a potential t-PA candidate comes in. He was alone when he arrived and I saw him and examined him immediately. His stroke, however, prevented him from speaking, and I needed more information in order to determine whether we could in fact treat him with t-PA. So it was with a sense of relief that I saw his adult daughter come into the room. She was a professional, middle-aged lady who was very appropriate in her demeanor as I explained the situation and the treatment options. I barraged her with a series of rapid-fire questions: information that was absolutely necessary to guide the decision to treat with t-PA. What time did the symptoms start? Was she there when it began? What did she notice first? Was Dad normal before the onset of symptoms?

Then her cell phone rang. I saw a moment of panic flit across her face as she reflexively pulled it out of its holster. I very deliberately ignored it and asked her the next question on my list. She was visibly torn. She knew that Dad was ill and that time was essential. She also knew the ER was very busy and that my time was limited. She clearly knew that it was inappropriate to answer the phone in this situation and I had all but told her so by continuing my questioning. I emphasized the point by repeating the question.And then she answered her cell phone anyway.

She did so with a furtive gesture, held it open a moment while she tried to answer my question at the same time, then half turned away and held the phone to her ear. "Yeah, I'm at the hospital. Dad's had a stroke. I can't - the doctor's here. I'll call you right back." She shut the phone and turned back to me with a chagrined look on her face. I ground my teeth just a little bit and we continued on with the conversation.

Now this is an extreme example, but this happens all the time and it drives me nuts! The crazything about this phenomenon is that these are normal, considerate people. I'm not talking about the losers out there - the immature adolescents who are simply more interested in talking to their friends, the Medicaideurs who abuse the ER and have no respect for the physician, that sort of thing. (They're easy to manage; I walk out of the room and leave them for another hour.) I'm talking about reasonable adults who clearly know that what they are doing is more important than the damn cell phone but they simply cannot prevent themselves from answering it! They have the grace to be embarassed, but they do not have the willpower to just let the call go through to voice mail.

Here's a clue, people: Sometimes it is acceptable to let a call go unanswered. Sometimes it is more important to focus on the person you are talking to in person than whomever is on the line. Especially when the person you are talking to is the treating physician for your family member.

Please make a note of it. This has been a public service announcement.

As the health care debate heats up, the American Medical Association is letting Congress know that it will oppose creation of a government-sponsored insurance plan, which President Obama and many other Democrats see as an essential element of legislation to remake the health care system.

I had hoped that the AMA's expressed support of health insurance reform would extend to this more fundamental element of reform, but it was a fool's hope. The AMA opposed national health insurance in the '30s and '40s, and opposed the creation of Medicare in the '60s. So it would have taken something of a sea change in the outlook of the AMA for them to support a role for government in a reformed health insurance market. The reasons given, however, are chickenshit at their heart. By which I mean that they are fundamentally dishonest about the real reason the AMA is in opposition. The pretext:

“The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans.”

WTF? Since when does the AMA - a doctor's association - carry water for our blood enemies in the insurance industry? Truth is, they don't. This objection is ideologically coded to imply that the doctors are open to lining up with the republicans, but the real reason is more crass and not fit for a public audience: a public plan could drive down the income of physicians. There, I've said it. Oh, wait, I've said it before, too. What the AMA really fears is a public plan which is, in the common parlance, too "robust," by which I mean it would have the option to set reimbursement at, say 110% of the Medicare rate, and that it would compel physician involvement. That would indeed be a bad plan. Having said that, it's not at all the only version of the public plan in the mix. Schumer's principles for a public plan explicitly contradict these worst-case fears of the AMA. Why then did the AMA not endorse their preferred version of the plan (if they were even aware of it?). I don't know. It goes back to my long-standing opinion that the physician's lobby is incompetent and ineffectual in national politics.

Today's New York Times story creates a false impression about the AMA's position on a public plan option in health care reform legislation. The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of a public plan that are currently under discussion in Congress.

Yeah, I'm thinking that Nancy Nielsen saw the NYT headline and did a spit-take: "I said what?" And realized that maybe, just maybe, it might not suit the doctors' lobby to be on the wrong (i.e. minority) side of the "who's for dinner?" game being played in Washington DC.

Boy it's frustrating to have these guys as "our" advocates in Washington when it seems that they couldn't find their asses with two hands and an ass-finding device.

10 June 2009

Pollster.com's Mark Blumenthal relates a memory of the Holocaust Museum and his family:This is Personal

I have a special memory of Pop (as we knew him) from last summer. It was a few weeks before he received his cancer diagnosis, during what turned out to be his last visit to the Holocaust Museum. Because he lost his parents and all of his siblings to the Nazis, and because no grave site exists for any of his family, Pop made it a habit to visit the Museum at least once a year. It fulfilled for him the custom that many Jews practice of visiting the cemetery of loved ones once a year. I only got to accompany him on one of these visits, that one last year, along with my wife's nephew Jake.

We wandered into the museum, through the same doors and into the same foyer where shots rang out this afternoon. My wife had given us visitor passes that she receives as a member of the Museum. The lines were long, and it was not obvious which line we needed to stand in.

Pop was having none of it. He walked away from me and wandered up to the museum staffer standing at the head of the long line leading to the elevators that takes all visitors to the museum exhibits. I thought for a moment that Pop was going to ask directions. I was wrong.

He thrust out his arm in the direction of the staffer, displaying the number the Nazis tattooed on his arm at Auschwitz just a few inches from her face. Without making eye-contact and barely breaking stride, Pop kept walking. Understandably, the staffer barely blinked. She didn't make a move to stop him.

I've been at the Holocaust museum and it was one of the most sobering and profound experiences of my life. I can't even imagine how sacred it must seem to those whose families were directly involved in The Shoah, and that this site was chosen for an act of anti-semitic violence is doubly tragic. The security guard at the museum has died from his wounds, and the white supremacist who shot him is in critical condition. Very sad. That controversial DHS report on the risk of right-wing violence is looking increasingly prescient now.

I joke that if it weren't for alcohol, anxiety and bad decisions we'd be out of business. I recently saw a patient for an exacerbation of her chronic pain syndrome. Despite being fairly young, she was totally debilitated and needed to use a walker. She was on massive doses of narcotics, including a fentanyl patch, methadone and percoset for breakthrough pain. Her accelerating use (and misuse) of her pain medicines had led to multiple ED visits and admissions.

When I saw her she was writhing in pain on a hallway gurney, inconsolable. I had to medicate her just to interview her, let alone perform an exam. It turned out, unsurprisingly, that she had been using her pain meds ahead of schedule and had run out of one of them. She basically wanted a refill. Unfortunately I had to inform her that it was our department policy that we don't provide refills for chronic pain medicines, as this is best managed by a primary care doc or a pain management specialist.

"But I don't have a primary care doctor," she pleaded.I was surprised. "So who has been writing your prescriptions to this point?""Dr Jones," she replied. I have known him for a long time and he's one of the better and more respected docs in the community. A stand-up guy who's famous for always being there for his patients."I think you're going to need to call Dr Jones' office in the morning to discuss your medicines," I informed her."But he's not my doctor any more! I fired him!""Why on earth did you do that?""He wasn't my advocate when I needed him to be, so I fired him. I'm through with him.""Wow," I said. "Did you really think that through? Who's going to maintain your meds?""I don't know," she wailed, "I have to find a new doctor in the next four days or I'm gonna go through withdrawal.""I'd really advise you to rethink Dr Jones. If nothing else keep seeing him until he can transition you to a new doctor.""No." Her refusal was flat and vehement. "I'm done with him. He abandoned me when I needed him."

I could not sway her, not that I tried too hard. I reviewed the office notes from Dr Jones' clinic (we share an electronic record) and I was astonished. This man had displayed the patience of Job in dealing with a very challenging personality. Dozens of phone calls, three or four per day sometimes, weekly office visits. Elaborate negotiations and agreements on narcotics, all of which had been violated by the patient, and he still kept working with her. And now he was repaid by HER firing HIM! Amazing. I never was able to figure out what perceived or imagined slight had pushed her over the edge.

Of course there was nothing I could do for her in the ER. I gave her a referral to the on call doc with a warning that he wouldn't be able to see her within four days and might well decline to write such high doses of meds for a new patient. I warned her that she would surely go through withdrawal, and while we could treat that, the ER was not going to provide her with replacement narcotics. I reminded her that all this could be avoided if she just went back to Dr Jones.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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